Chronic care management: Don’t leave money on the table

Nearly two years after the Centers for Medicare & Medicaid Services (CMS) launched CPT code 99490, many physician practices, especially smaller ones, are still hesitating to launch chronic care management (CCM) programs.

According to CMS, of the 35 million Medicare patients eligible for CCM programs, the agency has only received reimbursement requests for about 100,000 patients.

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Some of the reasons practices give for not participating are understandable: a CCM program can be resource- and labor-intensive to launch, and some costs are borne by patients in the form of copays for services provided between point-of-care visits.

But the fact remains that many practices risk leaving substantial money on the table-potentially tens of thousands of dollars per month-as value-based reimbursement in the form of Medicare payment reform and its Merit-based Incentive Payment System (MIPS), takes flight in the not-too-distant future. It’s all the more worrisome because many of the perceived challenges to launching a CCM program can be overcome at relatively modest costs and effort with the help of a partner.

Putting a price tag on care coordination services

CPT code 99490 is intended to help medical practices gear up for value-based reimbursement, and is aimed specifically at improving care of Medicare patients by enabling reimbursement for coordinating patient care services.

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The average Medicare beneficiary with two or more chronic conditions is under the care of five to seven providers. CPT code 99490 incentivizes one of these providers to manage each patient’s team of providers. In return, the lead provider can earn about $41 per month, per patient, in reimbursements for services that previously went unpaid. This specific code is just one member of a “family” of codes aimed at paying physicians to manage every step of a Medicare patient’s health journey, from initial diagnosis through transitions of care and even end-of-life-care planning. The goal is to improve quality of care while also increasing provider revenue.

Next: Challenges of starting CCM

Process-change fatigue and other challenges

Despite these benefits, practices are running into challenges when trying to get started on CCM. In many cases, it’s a lack of sufficient staff and resources. This is especially true for smaller practices, which are typically staffed for current care levels and where practice leaders believe they don’t have the additional staff hours, infrastructure or skill sets to implement a CCM program.

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Such programs may also be running into what I call “process-change fatigue.” Practices have been asked many times in recent years to modernize and adopt government initiatives-Meaningful Use and switching to ICD-10, for example. This has made it difficult for many to focus on their principal line of business, which is to deliver face-to-face care.

Reasons to get on board

All that being said, it’s in every practice’s best interest to get started soon on a CCM program, for several reasons. For one, all providers must recognize that, from a practical standpoint, some version of CCM ultimately will become mandatory within a few years as fee-for-service goes away and is replaced with value- and merit-based formulas. To realize maximum reimbursement-under Medicare and other similar models that may emerge-providers will have to demonstrate value, and one way that value will be measured is in how well physicians care for their chronically ill patients. 

Second, it’s important for providers to seize the opportunity sooner rather than later. Under CPT code 99490, just one physician can serve as the CCM team leader for any given patient. Practices that procrastinate could risk losing this role to another provider. Providers will be measured starting in 2017 on quality, advancing care information, clinical practice improvement and cost under MIPS. This will determine their Medicare reimbursement in 2019. Those who haven’t gotten on board are likely to find a surprisingly high number of patients already enrolled with other providers, and as a result, may lack the ability to demonstrate their individual contribution of value in the eyes of CMS.

Next: Potential financial gains

Only then will the financial ramifications of failing to launch a CCM program become truly apparent. Not only could such practices lose patient relationships, they could also miss out on the revenue generated by a CCM program. A recent report indicated that a practice with about 2,000 Medicare patients could generate more than $75,000 in net revenue per full-time physician if half of their eligible patients enrolled in chronic care management.

Even a small practice that enrolls 500 of its patients over a ten-month period can earn $160,000 in reimbursements in the first year and between $225,000 and $240,000 in the second year, once all eligible patients are enrolled. Revenue can continue to rise as a practice bills for other CCM-related codes, such as those associated with end-of-life care discussions. Practices could realize another 10% in reimbursements per code per year.

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Yet, even with all these reasons to get started now, some practices may still insist that they’re just too small to devote the time and resources to launching a CCM program.

What many of these may fail to realize is that the CMS codes allow providers to outsource development and administration of CCM to outside vendors.

Care coordination is no longer a nice-to-have, but a must-have, under Medicare’s changing quality and reimbursement programs. The time is literally now to make a plan for implementing systems like CCM to adapt to the massive economic opportunities and threats that each provider will ultimately face. Regardless of size, practices that are hesitant to get on board could be missing out on an opportunity to begin generating extra revenue, but more importantly, to focus more energy on what matters most: face-to-face time with patients.  

Travis Bond is CEO of CareSync, a medical practice solutions provider.